Is the change from NAFLD to MASLD driven by political correctness?
Authors: Madhusudana Girija Sanal
Journal: Journal of Hepatology (2023)

A multi–society Delphi consensus statement on new fatty liver disease nomenclatureJournal of HepatologyPreviewThe principal limitations of the terms nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are the reliance on exclusionary confounder terms and the use of potentially stigmatising language. This study set out to determine if content experts and patient advocates were in favour of a change in nomenclature and/or definition. Full-Text PDF Open Access The nomenclature of 'fatty liver disease' has undergone yet another change; this time from metabolic dysfunction-associated fatty liver disease to metabolic dysfunction-associated steatotic liver disease (MASLD).[1]Rinella M.E. Lazarus J.V. Ratziu V. Francque S.M. Sanyal A.J. Kanwal F. et al.A multi-society Delphi consensus statement on new fatty liver disease nomenclature.J Hepatol. 2023; https://doi.org/10.1016/j.jhep.2023.06.003Abstract Full Text Full Text PDF Google Scholar The change in the nomenclature was motivated not by any scientific rationale but by the stigma associated with the terms 'alcoholic' and 'fat'! In this instance, the term 'fat' is replaced with 'steato'. The use of Latin and Greek in scientific communication has become obsolete, as favoring common language aids layman comprehension, a vital consideration from a public health perspective. Citing stigma, pancreatic cancer should not be renamed 'pancreatic karkinos'. The message (about one's diagnosis) to the patient and public should be clear. In our survey, less than 1% of the 120 responders (nurses, paramedics, and university research students) knew the term steatosis. There is no reason for stigma because it is 'non-alcoholic' fatty liver disease and not 'alcoholic'. The term 'shouts out' that the patient is non-alcoholic! After all, stigma does not apply or reflect equally across different cultures or healthcare settings. For example, at least in some Indian languages, the equivalent of 'fatty' connotes with good health and would be regarded as a compliment! India is the 'diabetic capital' of the world and is home to the majority of patients with fatty liver; hence, in any democratic consensus, Indians deserve a larger representation! Further, 'steatosis' is a histological diagnosis and requires biopsy, precluding its usefulness for diagnosis in the community setting. Moreover, the continuously expanding volume of literature is complicating the search process, and frequent alterations in terminology will only exacerbate the challenge and uncertainty. Although the meaning and understanding of diseases evolve with time, upholding consistency in nomenclature is crucial for maintaining coherence in the literature. Exceptions should be made when unequivocal reasons exist. In this instance community and media responses suggest that this was not the case. Terms such as MetALD (alcoholism in fatty liver disease) further increases confusion.[2]Clinicians debate the usefulness of NAFLD name change n.d. https://www.medscape.com/viewarticle/995159?form=fpf (accessed August 16, 2023).Google Scholar The term 'non-alcoholic liver disease' has a long history. Klatskin an early President of the AASLD and colleagues, in 1979, were the first to use the term to describe the fatty livers seen in diabetic, obese, hypertensive, non-alcoholic individuals, which were characterized by fatty infiltration, Mallory bodies, neutrophilic infiltration, severe hepatocyte injury, and fibrosis on biopsy.[3]Reuben A. Leave gourmandising.Hepatology. 2002; 36: 1303-1306https://doi.org/10.1002/hep.510360543Crossref PubMed Scopus (11) Google Scholar Deficiencies in the term NAFLD were sufficiently discussed and published. Those objections were based on scientific grounds-firstly, NAFLD is not a single disease, as implied, but rather a spectrum of (polygenic) diseases leading to liver fat accumulation, tightly linked to 'metabolic syndrome'. Diseases once regarded as singular entities may actually comprise various diseases, occasionally arising from wholly distinct etiological processes! Therefore, it is more important to identify NAFLD primarily as a tool for clinicians to identify cardio-vascular-hepato-pancreatic-renal and carcinogenic risks in an individual (rather than as a disease). Secondly, the underlying pathogenesis can co-exist with other pathologies which can lead to fatty liver such as alcoholism or hepatitis C.[4]Sanal M.G. The blind men "see" the elephant-the many faces of fatty liver disease.World J Gastroenterol. 2008; 14: 831-844https://doi.org/10.3748/wjg.14.831Crossref PubMed Scopus (40) Google Scholar,[5]Sanal M.G. Nonalcoholic fatty liver disease: the concept and confusion.Minerva Gastroenterol Dietol. 2011; 57: 419-426PubMed Google Scholar,[6]Sanal M.G. Biomarkers in nonalcoholic fatty liver disease-the emperor has no clothes?.World J Gastroenterol. 2015; 21: 3223-3231https://doi.org/10.3748/wjg.v21.i11.3223Crossref PubMed Scopus (30) Google Scholar It is difficult to determine which etiology contributed more to the disease – fat, inflammation or fibrosis. This questions the value of the term MetALD in treatment planning. While the Delphi method is effective for reaching consensus, here the participants were limited to select organizations and were not representative of all stakeholders, including public health experts and family practitioners. Particularly when studying stigma, the involvement of actual patients and psychologists is paramount. About 60-70% of the participants felt the terms 'non-alcoholic' and 'fatty' to be stigmatizing. However, actual patients and policy advocates together formed only 9% of the panel. Further, how questions are framed in a questionnaire can influence the final poll results.[7]Kalton G. Schuman H. The effect of the question on survey responses: a review.J R Stat Soc Ser A. 1982; 145: 42https://doi.org/10.2307/2981421Crossref Google Scholar The method itself is associated with various biases such as incentive bias (because the panelists would be authors of an impactful paper), possible confirmation bias, Ben Franklin effect, courtesy bias, and acquiescence bias. If one reads carefully, fatty liver disease, steatotic liver disease (SLD), and lipogenic liver disease garnered 46%, 48% and 7% of first choice selections1. Less than half preferred SLD! It's possible that the term "steatosis" gained more support at a later point, potentially due to the strategy employed or persuasive factors. Important requirements of a disease nomenclature: 1) clarity of the intended message 2) ease and acceptability 3) reference to the pathology 4) consistency. The term MAFLD[8]Eslam M. Sanyal A.J. George J. International Consensus PanelMAFLD: a consensus-driven proposed nomenclature for metabolic associated fatty liver disease.Gastroenterology. 2020; 158: 1999-2014.e1https://doi.org/10.1053/j.gastro.2019.11.312Abstract Full Text Full Text PDF PubMed Scopus (1539) Google Scholar,[9]Sarin S.K. Eslam M. Fan J.-G. Lin H.-C. George J. Omata M. MAFLD, patient-centred care, and APASL.Hepatol Int. 2022; 16: 1032-1034https://doi.org/10.1007/s12072-022-10408-6Crossref PubMed Scopus (3) Google Scholar would make sense if it were defined as metabolic syndrome-associated fatty liver disease as it points to the cause and gives a clear message! There should be no room for confusion: 'fatty liver associated with 'which' metabolic dysfunction?'. If stigma is indeed a concern, more suitable terms such as lifestyle-associated liver diseases (LALD) could be better as most cases of NAFLD are associated with unhealthy lifestyle. In genetically predisposed individuals, an unhealthy lifestyle, such as lack of exercise and proper sleep and intake of excess calories, triggers the disease process. The term gives a direct message to the public that 'an unhealthy lifestyle can lead to liver disease' and thus urges them to adopt a healthy lifestyle and stop gourmandizing! The author received no financial support to produce this manuscript. The author declares no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. The following are the supplementary data to this article: Download .pdf (.16 MB) Help with pdf files Multimedia component 1